Oral Manifestations of Menopause

Transcription

1 Review Article Oral Manifestations of Menopause Kamal A. Shigli, Purushottam A. Giri 1 Department of Prosthodontics, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sangli, 1 Department of Community Medicine, Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences (Deemed University), Loni, Maharashtra, India ABSTRACT Oral health is an integral part of general health. Menopausal period has an important role in the reproductive life of a woman and gives rise to many physical and mental problems. The oral manifestations may vary for each patient in the form of burning mouth syndrome, xerostomia, mucosal changes, neurological disorders, osteoporosis, periodontitis, and eating disorders. As is the case in many developing countries like India, it is difficult for women to obtain access to healthcare services, as a result of a dearth of trained health care professionals at the grass root level and the specialized sector. It is the dentist s responsibility to treat them with care and refer postmenopausal women to a gynecologist for medical intervention, if necessary. This review attempts to provide an insight into the oral manifestations of menopause. Various internet based popular search engines were used to explore data from literature, which includes PubMed, PubMed Central, Google Scholar, Medknow, and Science Direct. Search was made using the key word combinations menopause ; and oral manifestations were used. The search was limited to reviews, meta analyses and assorted clinical reports were retrieved and evaluated. A total of 40 publications were evaluated for this article. KEY WORDS: Menopause, oral manifestations, symptoms, xerostomia INTRODUCTION India is the second most populated country after China. It has been estimated that by the year 2026, 173 million people will have age over 60 years and 103 million individuals will account for the menopausal population. [1,2] The World Health Organization defines menopause as the permanent cessation of menstruation due to loss of ovarian follicular activity. [3] Menopause means without estrogen and it is the time at which cyclic ovarian function known as menstruation ceases. Menopause is diagnosed retrospectively following 12 months of amenorrhea with no pathology. Menopause can thus be said to be a universal reproductive phenomenon. [4] Menopause may also be artificially induced by radiation, surgery and chemotherapy. [5] The terms menopause and climacteric are often used synonymously, but the two differ in that menopause refers Quick Response Code Access this article online Website: DOI: / X to the date of the last menstrual cycle and represents a shorter and defined period, while climacterium or perimenopause implies a much longer period with series of events, which eventually lead to loss of female reproductive capacity. [5,6] Menopause begins in the fourth decade of life and is heralded by a decrease in the menstrual flow which is followed by missed menses. [7] Three consecutive months of amenorrhea or average menstrual cycle lengths > 42 days are suggestive of approaching menopause. [8] There are a number of physical changes associated with menopause, some of which are manifested in the oral cavity. [9] The teeth and gums are more affected by the hormonal changes occurring before menopause, which decrease the body s ability to fight minor infections or maintain a healthy balance of useful and harmful bacteria within the oral environment. [10] The dentist needs to be aware of oral symptoms of perimenopausal, menopausal and postmenopausal women to be able to diagnose and treat such patients with extra care. [11] Thus, this review attempts to provide an insight into the oral manifestations of menopause. Address for correspondence Dr. Purushottam A. Giri, Department of Community Medicine, Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences (Deemed University), Loni , Maharashtra, India. E mail: drpgiri14@gmail.com 4 Journal of Basic and Clinical Reproductive Sciences January - June 2015 Vol 4 Issue 1

2 METHODS OF LITERATURE SEARCH The materials for this review were obtained from an extensive search using Medical Subject Headings of electronic databases which included PubMed, PubMed Central, Google Scholar, Medknow, Science Direct and Textbooks were searched until Literature on the effect of menopause on the oral cavity was retrieved. The key words used for the literature search included menopause and oral manifestations. The search was limited to reviews, meta analyses and assorted clinical reports were retrieved and evaluated from 1989 to 2013 in English. A total of 46 articles was identified. After examining the titles and abstracts, this number was finally reduced to 40 articles. A summary of oral manifestations of menopause by various authors is depicted in Table 1. Oral changes at menopause and their management The patient could manifest any of the following: Burning mouth syndrome Burning mouth syndrome (BMS) is an idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa, in whom a medical or dental cause has been excluded. [12] BMS was previously described as glossodynia, glossopyrosis, stomatodynia, stomatopyrosis, sore tongue and oral dysesthesia. [5,12] It mainly affects the tongue and sometimes the lips and gums. The symptoms are usually burning sensation which is usually bilateral and may be associated with alterations in taste (dysgeusia) and breath, dry mouth, swallowing difficulties and facial or dental pain. [5,6,8,10,13,14] Table 1: Various authors article on oral manifestations of menopause with key messages Authors Article title and article type Key message Frutos et al. [5] Dutt et al. [10] Mutneja et al. [11] Steinberg [14] Chaveli López et al. [17] Oral manifestations and dental treatment in menopause (review article) Oral health and menopause: A comprehensive review on current knowledge and associated dental management (review article) Menopause and the oral cavity (review article) BMS Burning mouth syndrome Women s oral health issues (review article) Dental considerations in pregnancy and menopause (review article) Xerostomia, lichen planus, benign pemphigoid, Sjogren s syndrome and burning mouth syndrome, periodontal disease. Use of salivary substitutes and control of bacterial plaque is recommended Periodontal health, dry mouth and burning mouth, oral mucosal and dental diseases, such as candidiasis. Hormone replacement therapy is effective but it does not necessarily prevent or help women with oral symptoms BMS, xerostomia, mucosal changes, neurological disorders, osteoporosis, periodontitis, eating disorders Oral discomfort, oral mucosal changes, salivation, osteoporosis, eating disorders Periodontitis, maxillary osteonecrosis, burning mouth syndrome, xerostomia, lichen planus, benign mucosal pemphigoid and Sjögren s syndrome Burning mouth syndrome mainly affects women, particularly after menopause. [5,6,10,12,15,16] Burning mouth can be caused by infections, allergies, vitamin deficiencies, and ill fitting dentures, leading to problems identifying effective treatments. [5,6,12] It may also be associated with Sjogren s syndrome or post radiation treatment in the head and neck region. [5,15] In some cases, it may be associated with psychogenic factors, such as anxiety, depression, or personality disorders. [5,6,12] People with BMS may show altered sensory and pain thresholds, or other signs of neuropathy. [12] Meurman et al. studied the relationship between oral discomfort and the menopause in 149 women and observed that the prevalence of oral discomfort was significantly higher in perimenopausal and postmenopausal women (43%) than in their premenopausal counterparts (6%). [16] It has been suggested that female sex hormones and neuropathic factors may be implicated, possibly through small fiber sensory neuropathy of the oral mucosa. [11,17] Variable results have been obtained following treatment of BMS in menopausal women with hormone replacement therapy (HRT), low dose topical/systemic clonazepam, psychological counseling, and tricyclic antidepressants. [5,10,11,15 17] Acupuncture has also been reported to be useful in reducing the burning sensation. [18] In denture wearing patients, a careful evaluation of denture fit and the foundation tissues is indicated, since denture adjustment or replacement may help to eliminate chronic irritation. [5] In instances, where burning mouth is due to allergy to acrylic denture base, it may be replaced with a metal denture base. [19] Xerostomia Xerostomia also known as dry mouth is another frequent symptom in postmenopausal women. [5,20] The patients typically report a decrease in salivary flow, though in only one third of all cases is hyposialia actually present. [17] Compared to premenopausal women, postmenopausal women have decreased unstimulated and stimulated submandibular and sublingual salivary gland flow, which is unrelated to any medication effect. [6,8] A decrease in gonadal hormones at menopause is associated with a decrease in salivary flow and salivary composition. [21] Ben Aryeh et al. [22] observed significantly altered salivary composition in the women pointing to sympathetic activation due to psychological stress with increase in salivary IgA and total proteins, while others have not been able to delineate any alterations in salivary volume/composition. Agha Hosseini et al. [23] observed a negative correlation between severity of dry mouth sensation and salivary concentration of beta estradiol. Xerostomia may lead to an increase in caries, periodontal disease, glossodynia, dysgeusia, unpleasant metallic taste, oral candidiasis, difficulty swallowing and difficulty wearing removable dental prostheses. [6,8,15,21] Treatment involves Journal of Basic and Clinical Reproductive Sciences January - June 2015 Vol 4 Issue 1 5

3 abundant water intake, together with sugar free sweets or chewing gum to increase salivation also, in some cases sialogogues such as pilocarpine, bromhexine or bethanechol may be indicated. [10,11,16,17] Adequate oral hygiene (use of interproximal brushes, dental floss, brushing frequency and technique) together with chemotherapeutic agents such as chlorhexidine aids in reduction of the accumulation of dental plaque. [5,10,11,17] Use of toothpastes, varnishes or gels containing fluoride is advised for the prevention of dental caries. [5,10,11,16,17] Mucosal changes The oral epithelial maturation process is affected during menopause due to decrease in estrogen levels, leading to thin and atrophic epithelium. [23] An increase in certain mucosal disorders such as oral lichen planus, pemphigus vulgaris, benign mucosal pemphigoid, or Sjögren s syndrome has also been documented. [5,8,17] Female patients can report with menopausal gingivostomatitis. The gingiva and remaining oral mucosa are dry and shiny, vary in color from abnormal paleness to redness, and bleed easily. [14,24] Fissuring occurs in the mucobuccal fold in some women and comparable changes may occur in the vaginal mucosa. [24] In patients with xerostomia and sensitive mucosal tissues, a tooth and or implant supported restoration should be favored above soft tissue supported restorations. [20] Neurological disorders Trigeminal neuralgia is also known to occur frequently in postmenopausal women owing to compression of superior cerebellar artery on any one of the branches of trigeminal nerve. [8,11] It is characterized by unilateral electric shock like pain in the middle and lower third of the face. [11] Long term estrogen deficiency arising from menopause seems to be related to a higher risk of developing Alzheimer s disease. [8] Osteoporosis and periodontitis Osteoporosis is a metabolic bone disease characterized by low bone mineral density or bone mineral density (BMD) that leads to fragility and susceptibility to bone fracture. [8] Estrogen receptors on the bone resorbing osteoclasts recognize the paucity of estrogen and respond by increasing their activity, while estrogen receptors on the bone forming osteoblasts respond by decreasing their activity. [8] The susceptibility to progressive periodontitis and osteoporosis enhances following menopause. [11,25 27] The exact pathogenesis remains unclear although increased accumulation of bacterial plaque and estrogen/serum osteocalcin deficiency have been suggested as etiological factors. [11,16,26,28] A study by Bullon et al. in 39 postmenopausal women, found low serum osteocalcin levels to be significantly correlated to a greater reduction in pocket depth and attachment loss after periodontal treatment. [28] Study by Kribbs [29] found that women with severe osteoporosis were three times more likely to be edentulous than healthy, age matched controls. Postmenopausal women have increased susceptibility to osteoporosis, so dental radiographs may demonstrate hypocalcified bone. [21,30] Osteoporotic patients require new dentures much more often than non osteoporotic patients. [9] A study was conducted by Ortman et al. [31] to determine the association between the degree of residual ridge resorption, sex and the age of the patient. Although analysis of data demonstrated a significantly larger percentage of women with class III (severe) residual ridge resorption (P < 0.05), the difference could not be related to the occurrence of menopause. Yüzügüllü et al. [32] evaluated the relation between alveolar bone loss and radiomorphometric indices and concluded that alveolar bone loss and bone heights were not affected by age or gender. A study by Taguchi et al. [33] suggested that postmenopausal women with missing teeth may have a higher risk of hypertension and subsequent vascular diseases than do those without missing teeth. Palomo et al. [34] concluded that postmenopausal women were not aware of their periodontal health and the risks involved to their systemic health. They suggested creating a taskforce comprising of periodontists, generalists, communication experts, and women at large, to develop informational guidelines. Cortical measurements detected on dental panoramic radiographs may be useful for identifying younger postmenopausal women with low BMD or osteoporosis. Dentists should refer postmenopausal women with eroded cortex or thin cortical width (<3.0 mm) for bone densitometry. [35] Estrogen treatment decreases the risk for tooth loss. [25,36,37] This benefit may be because of estrogen inhibition of cytokine production in inflamed gingiva and in bone cells in the jaws. Studies have shown the beneficial effects of HRT on gingival bleeding and on mandibular bone density. [25,37] Studies also suggest that bisphosphonates (BP) slow the resorption of alveolar bone of the maxilla and mandible. [25,27] There has been concern about bisphosphonate associated osteonecrosis of the jaw (ONJ). However, bisphosphonate doses for treating osteoporosis are much lower. [26] Treatment with oral Alendronate and Risedronate therapy have been noted to improve periodontal status. [26,27] Patients with osteoporosis have no contraindications to dental implant placement. Nevertheless, proper oral hygiene prior to intervention will be highly advised. Although the risk of ONJ in subjects treated with BP is very low, patients should be informed and must sign consent with the inclusion of this specific point. [38] 6 Journal of Basic and Clinical Reproductive Sciences January - June 2015 Vol 4 Issue 1

4 Eating disorders Changes in dietary habits may be induced during menopause. [6,39] Individuals with loss of sensitivity to sweet tastes may sweeten foods with potentially serious consequences, especially for those with diabetes mellitus, cardiac disease or obesity. [39] Psychological distress in menopausal women may lead to eating disorders. Oral changes may arise from self induced vomiting and resultant regurgitation of gastric contents. [11,14] Smooth erosion of enamel or perimylolysis; enlargement of the parotid glands; trauma to the oral mucous membranes and pharynx resulting from usage of fingers, combs, and pens to induce vomiting; angular cheilitis; dehydration and erythema may be observed in menopausal women suffering from eating disorders. [14] CONCLUSION Menopause is an important phase in a women s life, where oral health cannot be neglected. Dentists need to treat them with care taking into account the systemic changes, which the patient is undergoing. Women need to be educated regarding the changes in the oral cavity and the care to be taken. To make all this possible dentists need to work in close consultation with the gynecologist by referring postmenopausal women with oral symptom to a gynecologist for medical intervention if necessary. Recommendations Dentists should be aware of the effects of menopause on dental health. The following points should be stressed. [20,26,27,40] Patients dental complaints and their expectations about treatment should be clearly defined to avoid any unrealistic expectations Dentists should include a question in the health history form about menopausal status, which would identify menopausal or postmenopausal women Regular dental visit to confirm implementation of oral hygiene Brushing twice daily with a fluoridated toothpaste Replacing tooth brush every 3 4 months Using a dental floss or an interdental cleaner to clean interproximally between the teeth Maintaining a balanced diet Maintain an adequate Vitamin D status to prevent and treat osteoporosis associated periodontal disease. ACKNOWLEDGMENT The authors would like to acknowledge the cooperation extended by Dr. Banashree Sankeshwari, Senior Lecturer; Dr. Deepti Fulari, Senior Lecturer and Dr. Kalyani Marathe, Assistant Professor, Department of Prosthodontics, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sangli, Maharashtra, India for valuable inputs in the manuscript. REFERENCES 1. Unni J. Third consensus meeting of Indian Menopause Society (2008): A summary. J Midlife Health 2010;1: Dahiya P, Kamal R, Kumar M, Niti, Gupta R, Chaudhary K. Burning mouth syndrome and menopause. Int J Prev Med 2013;4: Research on the menopause in the 1990s. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser 1996;866: Lock M. Contested meanings of the menopause. Lancet 1991;337: Frutos R, Rodríguez S, Miralles Jorda L, Machuca G. Oral manifestations and dental treatment in menopause. Med Oral 2002;7:26 30, Santosh P, Nidhi S, Sumita K, Farzan R, Bharati D, Ashok K. Oral findings in postmenopausal women attending dental hospital in Western part of India. J Clin Exp Dent 2013;5:e8 e Nelson HD. Menopause. Lancet 2008;371: Friedlander AH. The physiology, medical management and oral implications of menopause. J Am Dent Assoc 2002;133: Zachariasen RD. Oral manifestations of menopause. Compendium 1993;14: Dutt P, Chaudhary S, Kumar P. Oral health and menopause: A comprehensive review on current knowledge and associated dental management. Ann Med Health Sci Res 2013;3: Mutneja P, Dhawan P, Raina A, Sharma G. Menopause and the oral cavity. Indian J Endocrinol Metab 2012;16: Buchanan JA, Zakrzewska JM. Burning mouth syndrome. Clin Evid (Online) 2010;2010;pii Zakrzewska JM. The burning mouth syndrome remains an enigma. Pain 1995;62: Steinberg BJ. Women s oral health issues. J Calif Dent Assoc 2000;28: Laing LP, Koka S. Systemic health aspects and nutritional considerations for edentulous patients. In: Zarb G, Hobkirk JA, Eckert SE, Jacob RF, editors. Prosthodontic Treatment for Edentulous Patients: Complete Dentures and Implant Supported Prostheses. 13 th ed. St. Louis: Mosby, Elsevier Inc.; p Meurman JH, Tarkkila L, Tiitinen A. The menopause and oral health. Maturitas 2009;63: Chaveli López B, Sarrión Pérez MG, Jiménez Soriano Y. Dental considerations in pregnancy and menopause. J Clin Exp Dent 2011;3: Scardina GA, Ruggieri A, Provenzano F, Messina P. Burning mouth syndrome: Is acupuncture a therapeutic possibility? Br Dent J 2010;209:E Bhatia V, Bhatia G, Jain N, Jadon AK. An innovative metal base denture design for a 55 year old menopausal woman. J Nat Sci Biol Med 2013;4: Zitzmann NU, Schilling J, Weiger R, Pastoret MH, Loretan P. Gender specific dental health issues and treatment considerations. Int J Prosthodont 2007;20: Akintoye SO, Collins MT, Ship JA. Diabetes mellitus and Endocrine diseases. In: Greenberg MS, Glick M, Ship JA, editors. Burket s Oral Medicine. 11 th ed.. Hamilton: BC Decker Inc.; p Ben Aryeh H, Gottlieb I, Ish Shalom S, David A, Szargel H, Laufer D. Oral complaints related to menopause. Maturitas 1996;24: Agha Hosseini F, Mirzaii Dizgah I, Mansourian A, Khayamzadeh M. Relationship of stimulated saliva 17beta estradiol and oral dryness feeling in menopause. Maturitas 2009;62: Klokkevold PR, Mealey BL. Influence of systemic disorders and stress on the periodontium. In: Newman MG, Takei HH, Klokkevold PR, Journal of Basic and Clinical Reproductive Sciences January - June 2015 Vol 4 Issue 1 7

5 Carranza FA, editors. Clinical Periodontology. 10 th ed.. Philadelphia: W.B. Saunders Company; p Glowacki J. Impact of postmenopausal osteoporosis on the oral and maxillofacial surgery patient. Oral Maxillofac Surg Clin North Am 2007;19:187 98, vi. 26. Buencamino MC, Palomo L, Thacker HL. How menopause affects oral health, and what we can do about it. Cleve Clin J Med 2009;76: Bhardwaj A, Bhardwaj SV. Effect of menopause on women s periodontium. J Midlife Health 2012;3: Bullon P, Chandler L, Segura Egea JJ, Perez Cano R, Martinez Sahuquillo A. Osteocalcin in serum, saliva and gingival crevicular fluid: Their relation with periodontal treatment outcome in postmenopausal women. Med Oral Patol Oral Cir Bucal 2007;12:E Kribbs PJ. Comparison of mandibular bone in normal and osteoporotic women. J Prosthet Dent 1990;63: Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100: Ortman LF, Hausmann E, Dunford RG. Skeletal osteopenia and residual ridge resorption. J Prosthet Dent 1989;61: Yüzügüllü B, Gulsahi A, Imirzalioglu P. Radiomorphometric indices and their relation to alveolar bone loss in completely edentulous Turkish patients: A retrospective study. J Prosthet Dent 2009;101: Taguchi A, Sanada M, Suei Y, Ohtsuka M, Lee K, Tanimoto K, et al. Tooth loss is associated with an increased risk of hypertension in postmenopausal women. Hypertension 2004;43: Palomo L, Chitguppi R, Buencamino MC, Santos D, Thacker H. A need to educate postmenopausal women of their periodontal health. J Indian Soc Periodontol 2013;17: Taguchi A, Tsuda M, Ohtsuka M, Kodama I, Sanada M, Nakamoto T, et al. Use of dental panoramic radiographs in identifying younger postmenopausal women with osteoporosis. Osteoporos Int 2006;17: Ardakani FE, Mirmohamadi SJ. Osteoporosis and oral bone resorption: A review. J Maxillofac Oral Surg 2009;8: Paganini Hill A. Hormone therapy and oral health. Menopause Manag 2007;16: Mellado Valero A, Ferrer García JC, Calvo Catalá J, Labaig Rueda C. Implant treatment in patients with osteoporosis. Med Oral Patol Oral Cir Bucal 2010;15:e Delilbasi C, Cehiz T, Akal UK, Yilmaz T. Evaluation of gustatory function in postmenopausal women. Br Dent J 2003;194: Murray DL, Fried J. Dental hygienists knowledge of menopause and its potential oral manifestations. J Dent Hyg 1999;73:22 8. How to cite this article: Shigli KA, Giri PA. Oral manifestations of menopause. J Basic Clin Reprod Sci 2015;4:4-8. Source of Support: Nil, Conflict of Interest: None declared 8 Journal of Basic and Clinical Reproductive Sciences January - June 2015 Vol 4 Issue 1

6